Jun 14, 2021
Join Mercedes Carnethon as she interviews authors Brendon Bellows, Dhruv Kazi, and Kirsten Bibbins-Domingo to discuss two articles published in the special issue: “Cost-effectiveness of Hypertension Treatment by Pharmacists in Black Barbershops” (https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.051683 ) and “Scaling Up Pharmacist led Blood Pressure Control Programs in Black Barbershops: Projected Population Health Impact and Value” https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.051782.
Dr. Joseph Hill:
Welcome to Circulation on the Run. My name is Joe Hill and I'm the editor-in-chief of Circulation. In recent months, we witnessed horrific acts of discrimination and violence against African-Americans. We are shocked and appalled, but yet we also recognize that this is in many ways nothing new. At Circulation, we are highly committed, longstanding commitment to shining a bright light on these pervasive inequities. And we are not willing to simply catalog the woefully longstanding racism that pocks our society, but rather we intend to shine a bright light on solutions. And with that, we are launching the first annual issue on disparities in cardiovascular medicine. This will be released in mid June corresponding to the date of Juneteenth, which is the date in the 19th century when a group of slaves in Galveston, Texas was apprised of the fact that they were no longer slaves now for two years.
Dr. Joseph Hill:
I'm honored to have our three editors who are running this podcast and this issue with us, they are Dr. Mercedes Carnethon from Northwestern University, Dr. Karol Watson from UCLA, both of whom are associate editors with the journal. And I'm pleased that Michelle Albert, who is one of our senior guest editors at UCSF will be joining us. These three professionals have led this initiative and I would like to spend a few minutes talking with them about this. First let's turn to Michelle if I may. Michelle, what do you think is required from a workforce perspective to make headway, to eliminate these disparities?
Dr. Michelle Albert:
Thank you, Dr. Hill. And I would first say that it is an honor to have been able to participate in this disparities issue focused on African-Americans and health. First, I think that it is important for our audience to understand that the metrics actually behind a workforce. In cardiovascular medicine, only 13% of fellows are underrepresented fellows, meaning black or African American, Hispanic, or Latinx, native Americans, Alaska natives, and Pacific Islanders. And only 9% of faculty are UIM in cardiovascular medicine. This stems from a pipeline or pathway issues that go all the way back to kindergarten and middle school. Indeed, over the last three decades only, although there's been a 50% increase in applications for blacks and Hispanics, the applications have only increased by 1.2% and there has been a drop in Alaska native and American Indian applications by 30%.
Dr. Michelle Albert:
So with regards to how improve these statistics, we have to have multifaceted approaches related to understanding pipeline barriers, which include things like lack of encouragement, lack of role models and paying attention to recruitment, but not just the only recruitment at the pre-medical level, immediate pre-medical level, but way prior to the pre-med level, we have to engage middle-aged and high school students in STEM and thereafter at the pre-medical level, we have to make sure that students get the appropriate advice to ensure successful careers in college that would then engender successful applications to medical school.
Dr. Michelle Albert:
Once we get into the actual medical institutional systems, we have to address structural barriers to discrimination that exist, that impede the progress through pathways in medicine. And these barriers exist at the medical school level, the residency level, fellowship level and faculty to leadership levels. I would say just a couple of examples at the medical school level to address would be actually paying attention to the fact that MCAT scores, we need to pay attention to a whole range of MCAT scores that focus on success in medical school and not just a specific hard cutoff. In residency we need to focus on evaluation disparities for UIM versus non UIM that then set the pathway again for a lack of progress into extremely competitive specialties like cardiovascular medicine. At the fellowship level we know that only 6% of program directors actually value diversity as one of the top three entities when ranking applicants. Duke School of Medicine actually had a really innovative process of holistic review and at all levels there should be holistic review that pays attention to distance, travel and metrics as well as attributes.
Dr. Michelle Albert:
And at Duke for example, what they did was they tripled actually their UIM enrollment in cardiology fellowship from 9% to 33% after employing a holistic review process that focus less on metrics and more on a combination of metrics, distance traveled, et cetera. Once folks are in the pipeline we have to set up systems of support to help trainees and faculty thrive in clinical learning and work environments because we noted small differences and assess clinical performance, amplify to large differences and evaluations, grades, and awards that have gone toward consequences for our workforce. And then I would say these are not my recommendations here or not all inclusive. But two other things I think that we really need to pay attention to besides the mentorship and sponsorship is actually stemming isolation for trainees and faculty within our structures and systems as well as ensuring that we all have implicit bias training and also the effect of implicit bias training is measured over time on the impact on healthcare outcomes and our pipeline outcomes. I know that was a mouthful, Joe, but this is a very complicated topic.
Dr. Joseph Hill:
Well, it certainly is Michelle. And I think all our listeners know that you have been and are a major leader on an international scale around these topics. Thank you for your leadership. My next question has to do with building trust with black patients in terms of their willingness to engage with their physician and also participate in research studies and trials. Karol, Dr. Watson from UCLA, maybe you can comment on that.
Dr. Karol Watson:
Yes, I would be happy to. And I have to piggy back on what Michelle just said. You start off talking about trust, there has to be a trust between the patient and the provider, the researcher and the participant, and that trust really it's multifactorial as Michelle states, but it really does rely on having a workforce that looks like the patient population, having principal investigators that look like the participants. We have an issue with trust in medicine in many areas, but one of them is lack of trust amongst African-Americans. When surveys are done and they ask patients to endorse or not endorse certain statements, the statement I trust my healthcare provider, it's less likely to be endorsed by African-American patients than others. And much of that mistrust is well earned. We're all aware of some horrific medical injustices that were meted out to certain communities, including African-American communities.
Dr. Karol Watson:
We're all aware of the Tuskegee syphilis study, but there are many others. So without trust, there really cannot be a healthy, collaborative care model that ensures optimal patient outcomes. So I think one of the most important things that we have to stop doing is thinking of blaming the patient for being, "Nonadherent, non-compliant, difficult," because many things go into that equation and much of it is on our backs. And as Michelle says, we have to diversify our workforce to start off. And I think there are so many other levels of Michelle really nicely laid out, but there are really so many other levels and including getting more African-Americans into clinical trials and we can't just do the same thing we've always done and expect to get different results. So we say, "Oh, African-Americans just won't up for research." Well, maybe we're not making that research relevant, appropriate, and easy for them.
Dr. Karol Watson:
If we ask people to come to our research centers between 8:00 and 5:00, Monday through Friday, when they're working three jobs and they have to watch their grandkids and they have no one to help. That's a very difficult ask, when you're asking people who are struggling for basic needs and basic survival to do extra things. It's a very difficult ask and we have to make it easier for them because I am of a firm belief that everyone wants to do the right thing. They want to help medical professionals get the research needed, do the right thing to care for their own health, but it has to be accessible and that's something we haven't done a great job doing.
Dr. Joseph Hill:
Well, thank you. What a challenge and that's why I think this issue that the three of you have spearheaded has helped move that needle around those sorts of questions. So my last question is a broad one and maybe even the hardest one that I will throw to Dr. Carnethon and that is what are the biggest remaining threats? What does the future look like when you put your headlights on high beam to solve these problems?
Dr. Mercedes Carnethon:
Well, thank you so much Dr. Hill, and it's great to follow my colleagues who've offered wonderful insights from multiple perspectives. When we think about the path forward, we have to really consider how we got here. And we didn't get here solely through faults in one system, for example, academic medicine, we got here because of the broader systemic and structural issues that have led to differences in access, that have led to the mistrust we're talking about and that have led to fewer opportunities for academic advancement for black adults within this country. And the path forward is going to have to be a collaborative path. It can't just be the researchers and clinicians within academic medicine making a change because we can't make those changes and reach out in isolation of the context in which the patients who were seeking to help live in. So it requires partnerships with individuals at the community level, so that we can think about how we roll out effective interventions.
Dr. Mercedes Carnethon:
So those interventions that work one-on-one how do we get those out to the people who need them the most? That requires partnerships with the community and even changing the environments in which people live, making them healthier. It requires partnerships with academic institutions building off of the point that Dr. Albert made about needing to start and bolster the pipeline early so that we can get researchers and clinicians who look like the patients that they're trying to serve. And ending as well with Carol's point, when we run a study and we don't have representation from across a range of socioeconomic status from multiple individuals, black individuals, white, other races and ethnicities, we don't know how well those therapies are going to work, or whether there are unique situations that are going to lead them to be less effective in one group versus another. So I think I would end really with the point that the path forward to promoting equity is one that's going to involve partnerships across multiple different domains. And I do feel very hopeful that we can get there, especially as we're calling attention to these important issues right now.
Dr. Joseph Hill:
Well, I will end by saluting the three of you because you are in fact pointing away to a path forward and concrete things to make a difference. And it is my pleasure and honor to work with the three of you leaders. And I'm so proud of this issue, which will be a recurring issue and in June of every year. And thank you again for what you've done, you're making an important difference in our world.
Dr. Karol Watson:
And thank you so much for Dr. Hill for spearheading and supporting this effort. It is so important.
Dr. Mercedes Carnethon:
Yes, thank you.
Dr. Joseph Hill:
My pleasure.
Dr. Michelle Albert:
It's indeed an honor. And we have to lead by example, and I hope that we do.
Dr. Mercedes Carnethon:
Thank you so much.
Dr. Mercedes Carnethon:
I'm really excited as we move past our discussion amongst the editors to have an opportunity in this podcast to also speak with a team of authors who submitted two papers to our very special issue we have with us today, Dr. Brandon Bellows, Dr. Kazi and Dr. Kirsten Bibbins-Domingo who are sharing their findings about pharmacist led interventions to manage blood pressure among black Americans in barbershops. So thank you so much for submitting your important work to Circulation. I'd like to start with questions for you, Dr. Bellows. So your particular manuscript is addressing the cost effectiveness of hypertension treatment by pharmacists in black barbershops. Thank you for working on this very important work, because it really extends some of what we talked about earlier, which is the need to scale up and disseminate what we know to be effective interventions in populations. So can you tell us a little more about what you studied and what was unique?
Dr. Brandon Bellows:
Yeah, thank you so much. So we studied the value of a program to bring clinical pharmacists into black owned barbershops as you mentioned, and have the pharmacist partner with the barbers to manage hypertension in black men. As we know, black men are disproportionately impacted by both hypertension and cardiovascular disease. So our work was based on a randomized trial that was performed in barbershops in Los Angeles County. And this was led by the late Dr. Ron Victor. So we're really building upon his great foundation. In that trial they found that the pharmacist-barber collaborations substantially reduced systolic blood pressure by over 20 millimeters of mercury, relative to Barber's providing education alone over one year. So given that having pharmacist drive around barbershops and Los Angeles is a very expensive proposition, but we wanted to know if the potential benefits long-term would outweigh some of those high upfront costs and would it be a cost-effective to do this in Los Angeles? So really focused on the trial.
Dr. Brandon Bellows:
So to do this, we combined the data from the randomized trial with our computer simulation model to try and project long-term clinical outcomes. So upto 10 years, so for both blood pressure, cardiovascular disease events, as well as the economic outcomes. So total healthcare costs, costs of the program and so on. So what we found was that having pharmacists work with barbers and these black owned barbershops was a cost-effective way to reduce blood pressure in black men. Over 10 years, we projected that the program would cost about $2,400 more, and that's total healthcare costs than barbers providing education alone so they enter the control arm in the trial, and we found that they would prevent about 30% of cardiovascular disease events over 10 years. So the incremental cost effectiveness ratio or ICER, which is how we define cost-effectiveness was $43,000 per quality adjusted life year gained.
Dr. Brandon Bellows:
And this is below the threshold recommended by the American Heart Association of $50,000 per quality adjusted life year gained to define something as highly cost-effective. So doing this with a highly cost effective way to improve blood pressure in black men. So one thing that makes our study unique is that our computer simulation model allows us to explore different designs of the program to see how that might impact the cost effectiveness. So for example, if we were to use only generic antihypertensive medications, or if we were to decrease the length of the intervention from one year to six months, the pharmacist barber program was even more cost effective. So given the long-standing disparities in cardiovascular disease that have been experienced by black men in the United States, we're really hoping that how our research can help motivate healthcare payers to adopt these kinds of non-traditional approach delivering hypertension care, because if nobody's paying for it, then there's not going to be uptake in the community.
Dr. Mercedes Carnethon:
Yeah. Brandon, thank you so much for sharing that and sharing the details about what you found. I love this line of work because quite often we've spent a lot of time discussing and describing disparities, but less attention considering ways in which we can reduce disparities by reaching people where they are. So that brings me to you Kazi. So your study uses the same population, but addresses a slightly different question that I think is very relevant to our audience as we seek to try to promote cardiovascular health equity. So tell us a little bit about what you did in the same population and what you found.
Dr. Dhruv Kazi:
I want to also start out by acknowledging that the study is anchored in the vision and genius of the late Dr. Ron Victor, who ran the barbershop based blood pressure controlled studies in Dallas, and then in Los Angeles. And kind of motivated by his pragmatic optimism, this idea that we have a problem where others high rates of uncontrolled blood pressure in black men, but it is a problem that can be addressed through a novel intervention that will then have to be contextualized. He was open-eyed about the need for contextualization that even though there's a large 20 millimeter mercury reduction in blood pressure, any intervention, when we go beyond Los Angeles would have to be contextualized for geography and for payer. Would treating blood pressure in Dallas, or San Francisco, or Detroit, or Atlanta would look different from both the economics and the practical aspects of delivering this care in Los Angeles?
Dr. Dhruv Kazi:
So we set out to ask the question that if we were to make these barbershop based pharmacists led blood pressure control programs more widely available across the country in urban areas, metropolitan areas, and were able to enroll black men with uncontrolled blood pressure into these programs, what would the clinical impact be and what would the economic constraints be for these programs to be sustainable? We estimated that about 950,000 black men could be enrolled in a program of this nature. So that's about a third of black men with uncontrolled hypertension and that doing so on an annual basis would reduce about 8,600 or 8,600 major adverse cardiovascular events. That's about including 1800 MIs and 5,500 strokes. So quite a large number of events, but 40% of events in enrolled populations. And we then set out to ask, "Well, that's great. If we could deploy these programs at scale, there's the potential for substantial clinical impact, what would the economic constraints have to be for this program to be sustainable?"
Dr. Dhruv Kazi:
So if we imagine that this were not a delivery program but rather a pill, and you were willing to pay $100,000 to reduce per quality adjusted life here for blood pressure control medication, how much would we be willing to pay for this barbershop based program? And we found that approximately it would have to be delivered at a cost of $1,400 per patient per year. Now, $1,400 per patient per year is a substantial amount of money when you scale it up across the entire eligible population, but at the same time would require innovation and delivery that goes beyond pharmacists driving from one barbershop to another. So what we hope is that our work will stimulate this conversation around how can we take this intervention that is highly effective, that is potentially scalable and adapted in a way that we can afford to deliver it nationwide without losing effectiveness that we saw in the Los Angeles trial?
Dr. Mercedes Carnethon:
Thank you so much Dr. Kazi. And this just generates a lot of discussion as we really think about how we can bring interventions to people and how we can have an impact. So Kirsten, I'm so pleased that you were also able to join us as one of the senior authors, senior members of these research teams, because we really value your perspectives as well about where do the findings from this study situate us in the field. How do we move forward to achieve our goals of achieving equity and particularly among black patients and black adults in this country who we know have experienced significantly higher rates of hypertension and hypertension related disorders, we have a significant need here. So tell us how do we use this important information in order to make a difference?
Dr. Kirsten Bibbins-Domingo:
Thank you so much for having us and congratulations on this really important issue.
Dr. Kirsten Bibbins-Domingo:
I think what we see here in why these papers and this work is important is that it is really trying to take the important science that we're producing, trying to aim that addressing disparities and put it in the context that we could ideally rapidly translate it to actually help and address this issue. And with hypertension, we have both the urgency of declining rates of blood pressure control in the US as well as the persistent disparities that we see. So we have this effective intervention marrying a care provided by clinical pharmacists with community-based venues and partnership with black barbershops that is highly effective. The detailed studies led by Brandon really suggest that even in LA, pharmacists driving around this is a cost-effective intervention and that if we were to scale it, it could actually reach a lot of black men in the US and even though $1400 per person per year is a lot of money, it's actually not out of context of other things that we do that are high priority for our healthcare systems.
Dr. Kirsten Bibbins-Domingo:
So what we hope is that these two papers together help us to start to bring more people to the table to how we can translate now an effective trial, a trial that can effectively scale in a cost-effective way to thinking about what we could actually do. So how might this look? We think this is something that we hope health systems start to engage in. When they see disparities in the care for their members, for their patients, how could they think more creatively?
Dr. Kirsten Bibbins-Domingo:
How could payers, how could Medicaid for example, think about incentivizing different ways of delivering hypertension care? How could we think in other contexts about departments of public health or cities that really want to have a population-based approach to improving cardiovascular health? And money isn't everything, but is an important thing that many of these entities are thinking about and understanding both that this is a cost-effective intervention and that the amount per person to actually achieve this important role in cardiovascular health is not out of scale for other things that we prioritize in terms of health I think is important and that's what we hope people will take away from these important studies.
Dr. Mercedes Carnethon:
Wow, I really appreciate the time and attention that your team put into designing these really high impact research studies that achieve what our goal is, is to really think about ways in which we can address and eliminate disparities. I've really loved hearing about this work, and I hope that a broad audience receives it and really thinks about some of what we talked about before, which are the multiple different parties and disciplines that are required to come to the table for us to effectively address disparities. So thank you so much for spending time with us at our Circulation on the Run podcast, Dr. Kirsten Bibbins-Domingo from University of California at San Francisco, Dr. Brandon Bellows from Columbia University College of Physicians and Surgeons and Dr. Kazi from Beth Israel Deaconess Medical Center. So thank you so much for spending time with us today.
Dr. Dhruv Kazi:
Thank you for having us.
Dr. Brandon Bellows:
Thank you. It's been a pleasure.
Dr. Mercedes Carnethon:
And finally, I'd like to end by thanking our listeners for spending time with us today. We hope that you enjoyed the podcast, and we hope that you will enjoy the issue even more.
Dr. Greg Hundley:
This program is copyright of the American Heart Association, 2021. The opinions expressed by speakers in this podcast are their own, and not necessarily those of the editors or of the American Heart Association. For more, visit ahajournals.org.